Combination Of Endoscopic Ultrasonography Research Articles

Endoscopic landmarks corresponding to anatomical landmarks for esophageal subsite classification.

Individual treatment strategies for esophageal cancer have been investigated based on the anatomical subsite classification. Accurate subsite classification based on these anatomical landmarks is thus important. We investigated the suitability of the existing endoscopic classification and explored alternative landmarks for esophageal subsite classification. Patients who received endoscopic ultrasonography (and computed tomography scans for surveillance of esophageal cancer treatment or esophageal submucosal tumors were included. Distances between anatomical landmarks, including the inferior cricoid cartilage border, superior border of the sternum, and tracheal bifurcation, were measured using a combination of endoscopic ultrasonography, computed tomography, and other information. The mean (standard deviation) distances from the superior incisor dentition to the pharynx-esophagus, cervical-upper thoracic esophagus, and upper-middle thoracic esophagus boundaries were 16.9 (1.7), 21.7 (1.9), and 29.0 (1.9) cm, respectively. However, variances in the differences between the mean and individual distances were large (2.8, 3.4, and 3.7, respectively), mainly because of differences in body height. However, variances in the differences between individual distances and novel endoscopic landmarks, including the lower end of the pyriform sinus and lower end of compression of the left main bronchus, were lower (1.7, 1.2, and 0.6, respectively). Existing indicators of esophageal subsite boundaries were not consistent with anatomical boundaries. Modification of the distance from the superior incisor dentition based on average distances from anatomical landmarks or the use of alternative endoscopic landmarks is recommended to provide more suitable anatomical boundaries.

Combination of Endobronchial Ultrasound and Modern Cytological Diagnosis in Patients With Intrathoracic Lesions

Objective: To evaluate the effectiveness of endobronchial (EBUS) and endoscopic ultrasound (EUS) in cytomorphological verification of a malignant process using the transbronchial needle aspiration (TBNA) of the lymph nodes and mediastinal organs.Materials and methods: In 2017–2019 we analyzed the cytological samples (standard and cell block) of 172 patients (115 males and 57 females) with an average age of 61 years (25–82 years) in the clinical diagnostic laboratory of Scientific Research Institute – Ochapovsky Regional Clinical Hospital No. 1 (Krasnodar, Russian Federation). Of them 111 were used for immunocytochemical analysis. The majority of the studies (77) were performed in patients with lung cancer in order to identify the stage of the disease. We used combined bronchoscopy under general anesthesia in the operating room with high-frequency ventilation and a rapid on-site evaluation (ROSE).Results: We found the lymph node and mediastinal invasion in 140 (81%) patients who underwent EBUS-EUS TBNA. The non-diagnostic results were obtained in 32 (19%) patients. The combination of EUS and EBUS with TBNA showed the highest effectiveness in the mentioned clinical cases. The sensitivity, specificity, and accuracy of the cytologic analysis during EBUS and EUS with TBNA and no ROSE were 89%, 100%, and 90%, respectively. ROSE reduced the rate of non-diagnostic results and increased the sensitivity (96%), specificity (100%), and accuracy (97%) of the cytologic evaluation.Conclusions: According to the obtained results, we recommend using EBUS-EUS TBNA modalities for morphological verification of the mediastinal lymph nodes as a routine invasive diagnosis component of the preoperative evaluation in patients with lung cancer.

Endoscopic Ultrasound Plus Endoscopic Retrograde Cholangiopancreatography Based Tissue Sampling for Diagnosis of Proximal and Distal Biliary Stenosis Due to Cholangiocarcinoma: Results from a Retrospective Single-Center Study.

Simple SummaryThe diagnosis of cholangiocarcinoma depends on several factors, including growth pattern and location. Previous studies have evaluated the diagnostic accuracy of endoscopic retrograde cholangiopancreatography based tissue sampling and endoscopic ultrasound with either fine-needle aspiration or fine-needle biopsy, reporting values < 80% for each procedure. Here, we describe the performance of both methods in a group of patients with a stricture of the biliary tract suspicious for cholangiocarcinoma. Our analysis confirms the high diagnostic accuracy of the procedures when performed together in distinguishing between a primary malignant or benign biliary stenosis. Differentiating between benign and malignant biliary stenosis (BS) is challenging, where tissue diagnosis plays a crucial role. Endoscopic retrograde cholangiopancreatography (ERCP)-based tissue sampling and endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) or biopsy (FNB) are used to obtain tissue specimens from BS. The aim of this retrospective study was to evaluate the diagnostic yield of EUS-FNA/B plus ERCP with brushing or forceps biopsy in BS. All endoscopic procedures performed in patients with BS at our gastroenterology unit were reviewed. The gold standard for diagnosis was histopathology of surgical specimens or the progression of the malignancy at radiological or clinical follow-up. A total of 70 endoscopic procedures were performed in 51 patients with BS. Final endoscopic diagnosis was reached in 96% of the patients and was malignant in 61.7% and benign in 38.3% of cases. Sensitivity, specificity, and diagnostic accuracy were 73.9%, 100%, and 80%, respectively, for EUS-FNA/B; 66.7%, 100%, and 82.5% for ERCP; and 83.3%, 100%, and 87.5% for both procedures carried out in the same session. The combination of EUS and ERCP tissue sampling seems to increase diagnostic accuracy in defining the etiology of BS. Performing both procedures in a single session reduces the time required for diagnostic work-up and optimizes resources.

Efficacy of endoscopic ultrasonography in evaluating tumor thickness in patients with superficial pharyngeal carcinoma: A pilot study

ObjectivesA histopathological tumor thickness of ≥1000 μm has been reported as one of many risk factors for recurrent lymph node metastasis in superficial pharyngeal cancer (SPC). However, methods for assessing this risk factor preoperatively have not yet been established. Hence, the current study aimed to evaluate the efficacy of endoscopic ultrasonography (EUS) in measuring tumor thickness preoperatively in patients with SPC. MethodsThis single-center retrospective study included 44 consecutive patients with 47 lesions who underwent endoscopic submucosal dissection (ESD). Prior to surgery, EUS examination was performed while under general anesthesia. Further, microvascular irregularity in the target lesion was evaluated using the Japan Esophageal Society (JES) magnification endoscopic classification system. ResultsA significant correlation was noted between histopathological and EUS tumor thickness (Spearman's correlation r == 0.879, p < 0.001). In tumors ≥1000 µm thick on histopathology, the cutoff value for EUS tumor thickness was 2.6 mm, and the following values were obtained: sensitivity, 100%; specificity, 81.8%; positive predictive value (PPV), 70%; negative predictive value (NPV), 100%; and accuracy, 87.2%. In B2 lesions ≥1000-μm thick, the following values were obtained: sensitivity, 85.7%; specificity, 90.9%; PPV, 80%; NPV, 93.8%; and accuracy, 89.4%. The diagnostic accuracy rate of combined EUS and the JES magnifying endoscopic classification system was 95.7%. ConclusionsTumor thickness assessed using EUS was effective in diagnosing histopathological tumor thickness of ≥1000 μm. The combined use of EUS and the JES magnifying endoscopic classification system may be useful for assessing preoperative risk factors for lymph node metastasis in SPC.

Diagnostic value of endoscopic ultrasonography, fibroscan, acoustic radiation pulse imaging, serological index, and their combination for early stage liver cirrhosis

Objective: To investigate the diagnostic value of endoscopic ultrasonography (EUS), Fibroscan, acoustic radiation force impulse (ARFI), and aspartate aminotransferase-to-platelet ratio (APRI) and their combination for early stage liver cirrhosis. Methods: Three hundred and twenty-two hospitalized patients who had been diagnosed with chronic viral liver disease from March 2016 to April 2018 were included. According to the clinical diagnosis, patients were divided into chronic hepatitis and the early stage liver cirrhosis group (Child-Pugh A grade). All patients were examined by Fibroscan to detect liver stiffness measurement (LSM), ARFI to detect liver virtual touch tissue quantification (VTQ) value, esophagogastroduodenoscopy and EUS to detect esophagogastric varices, laboratory and imaging examination. The index of EUS, Fibroscan, ARFI, and APRI was analyzed and the regression model was established by binary logistic regression, and the diagnostic efficacy of the above index and regression model for early stage of cirrhosis was evaluated by the area under a receiver operating characteristic curve (AUROCs). Results: An early stage cirrhosis group had significantly higher detection rate with EUS (esophagogastric varices), Fibroscan (LSM), ARFI (VTQ) and APRI than chronic hepatitis group [76.7% vs. 10.7%, 10.4 (7.8, 17.3) vs. 6.1 (5.2, 8.4) kPa, 1.71(1.48, 2.07) m/s vs. 1.25(1.14, 1.43) m/s and 0.65 (0.38, 1.15) vs. 0.38(0.26, 0.62), respectively]. The corresponding chi-square test were 140.86, Z = -9.069, Z = -9.948 and Z = -5.764, respectively and the differences were statistically significant (P < 0.01). The areas under the receiver operating characteristic curve and regression model were 0.830 (0.783 ~ 0.877), 0.793 (0.744 ~ 0.841), 0.821 (0.775 ~ 0.868), 0.686 (0.628 ~ 0.744) and 0.947 (0.925 ~ 0.969) for the diagnosis of early stage cirrhosis, respectively. Among them, the regression model of three indices (EUS, LSM and VTQ) had the largest AUROCs (0.947) and the corresponding sensitivity and specificity were 0.878 and 0.867, respectively. Conclusion: The combination of EUS, LSM and ARFI had a superior diagnostic value for early stage liver cirrhosis, and may improve the diagnosis rate and reduce the misdiagnosis rate.

Diagnostic value of endoscopic ultrasonography combined with liver stiffness measurement and liver histopathology for early liver cirrhosis

Objective To evaluate the value of endoscopic ultrasonography(EUS) alone for early liver cirrhosis and the diagnostic efficacy of EUS combined with liver histopathology (LH) and liver stiffness measurement (LSM) for early liver cirrhosis. Methods Data of 226 patients with chronic liver lesions who underwent endoscopy and EUS at Tianjin Second People's Hospital were collected to assess esophageal and gastric varices. Liver fibrosis was assessed by LH and LSM was determined by Fibroscan. Models of EUS-LSM, EUS-LH, LSM-LH, ELL (EUS, LSM and LH) were constructed to predict early liver cirrhosis. The ROC curve and AUROC were used to evaluate the efficacy of different models in the diagnosis of early liver cirrhosis. Results A total of 149 patients were diagnosed as chronic liver disease and 77 patients were diagnosed as early liver cirrhosis (Child-Pugh A grade) by clinical evaluation. Ratio of varices found by EUS was significantly higher than that by endoscopy [68.8% (53/77) VS 32.5% (25/77), P<0.05]. The cut-off value was 8.65 kPa by LSM to predict early liver cirrhosis. Pseudolobules were confirmed by LH in 42(54.5%) patients in the early liver cirrhosis group. The AUROC of ELL was 0.919 (95%CI: 0.875-0.951), sensitivity=0.792, specificity=0.913, PPV=0.824, NPV=0.895, + LR=9.08, -LR=0.23, accuracy=0.872, and ELL was superior to EUS (P<0.000 1), LSM (P<0.000 1), LH (P<0.000 1), EUS-LSM (P<0.000 1), EUS-LH (P=0.013 4) and LSM-LH (P=0.002 2) in the diagnosis of early liver cirrhosis. Conclusion EUS is superior to endoscopy in detecting the varices for early liver cirrhosis. Combination of EUS with LSM and LH can improve diagnostic efficacy for early liver cirrhosis. Key words: Ultrasonography; Pathology; Liver cirrhosis; Liver stiffness measurement

Diagnostic Accuracy of Preoperative Imaging for Differentiation of Branch Duct Versus Mixed Duct Intraductal Papillary Mucinous Neoplasms.

The aim of this study is to determine the diagnostic accuracy of preoperative evaluation to detect main pancreatic duct involvement in pancreatic cystic lesions thus differentiating mixed intraductal papillary mucinous neoplasm (IPMN) from branch duct (BD)-IPMN. The pathology database of pancreatic resections from 2000 to 2014 was reviewed. Main pancreatic duct-IPMNs and IPMNs with intracystic mass/nodules were excluded. The preoperative test characteristics were analyzed using surgical histopathology as the "gold standard." Sixty BD-IPMNs and 23 mixed-IPMNs were identified. Mixed-IPMNs were larger (mean [standard deviation], 4.14 [2.9] vs 2.74 [1.9] mm; P = 0.03) and demonstrated frequent high-grade dysplasia/adenocarcinoma (43% vs 12%, P = 0.004) than BD-IPMNs. Endoscopic ultrasound (EUS) (sensitivity, 80%; specificity, 78%; accuracy, 79%) had the best diagnostic accuracy, whereas magnetic resonance imaging (MRI) (sensitivity, 83%; specificity, 63%; accuracy, 68%) had the highest sensitivity for the diagnosis of mixed-IPMN. A combination of EUS and MRI reached maximum sensitivity but with decreased accuracy (sensitivity, 100%; specificity, 64%; accuracy, 67%). The area under the curve for receiver operation curve was 0.71 whereas the optimal cyst size to detect main duct involvement was 3 cm. For preoperative evaluation of pancreatic cystic lesions without evidence of intracystic nodules, a combination of MRI and EUS should be considered for improved detection of main duct involvement.

Predictive value of combination of endoscopic ultrasound and 64-slice dual-source computed tomography in regional clinical staging and peritoneal metastases of gastric cancer

Objective To analyze the predictive value of combination of endoscopic ultrasound (EUS) and 64-slice dual-source computed tomography (DSCT) in regional clinical staging and peritoneal metastases of gastric cancer. Methods From July 2011 to May 2017, 365 patients with gastric cancer diagnosed by endoscopic biopsy were enrolled. The patients received EUS and DSCT examination with the gold standard of postoperative pathological diagnosis, the accuracies of EUS alone, DSCT alone and the combination of EUS and DSCT were evaluated in original gastric tumor, regional lymph nodes and peritoneal metastases. The accuracy, sensitivity, specificity, the positive predictive value, the negative predictive value, consistency (the value of Kappa) and area under curve (AUC) of receiver operating characteristic (ROC) curve were calculated. Results A total of 263 patients were enrolled into the study on the depth of tumor invasion and clinical staging of regional lymph nodes and 289 patients were recruited into the clinical prediction study on peritoneal metastasis. The accuracy of EUS in clinical staging of the depth of tumor invasion was 75.29% and the sensitivity, specificity, the value of Kappa and AUC of EUS in clinical staging of regional lymph nodes were 86.26%, 81.81%, 0.681 and 0.840, respectively. The sensitivity, specificity, the value of Kappa and AUC of DSCT in clinical staging of regional lymph nodes were 74.81%, 87.12%, 0.620 and 0.813, respectively. The sensitivity, specificity, the value of Kappa and AUC of EUS in the prediction of peritoneal metastases were 38.24%, 97.25%, 0.432 and 0.668, respectively. The sensitivity, specificity, the value of Kappa and AUC of DSCT in the prediction of peritoneal metastases were 41.18%, 100.00%, 0.553 and 0.706, respectively. The accuracy and the value of Kappa of the combination of EUS and DSCT in clinical staging of the depth of tumor invasion were 75.29% and 0.639; the sensitivity, specificity, positive predictive value, negative predictive value, Kappa, AUC in clinical staging of regional lymph nodes were 93.13%, 87.88%, 88.41%, 92.80%, 0.810 and 0.905, respectively; and the sensitivity, specificity, positive predictive value, negative predictive value, Kappa, AUC in the prediction of peritoneal metastases were 58.82%, 97.25%, 74.07%, 94.66%, 0.616 and 0.774, respectively. Conclusions The combination of EUS and DSCT which is superior to single examination is very helpful in the depth of gastric cancer invasion and regional lymph nodes, and is helpful in the prediction of peritoneal metastasis. The combination of two complementary examinations can improve the accuracy of the depth of gastric cancer invasion, clinical staging of regional lymph nodes, and the prediction of peritoneal metastasis. Key words: Stomach neoplasms; Endosonography; Neoplasm staging; Tomography

EUS-Guided Transgastric Drainage of Intraabdominal Fluid Collections.

Intraabdominal fluid collections can be a significant cause of morbi-mortality among patients with acute pancreatitis and those who underwent surgery, especially oncological ones. Nowadays, the treatment tends to be minimally invasive, so that the patient's recovery would be shorter and the quality of life higher. EUS (endoscopic ultrasound) has emerged in the last decade to fulfill that demand, alongside percutaneous and surgical drainage in the management of perigastric collections. Objectives: The main objective of this paper is to evaluate the efficacy of EUS guided drainage in terms of techincal and clinical success. Secondary objectives refer to the assessment of complete resolution of intraabdominal collection, presence of infection after drainage, overall survival. Methods: We conducted a prospective study by enrolling 31 patients who were diagnosed using EUS with perigastric intraabdominal fluid collections, from an overall of 788 EUS performed over a period of 2 years. We analyzed their evolution during 6 months after treatment, by regular examinations (ultrasound/endoscopic/computed tomography). All of them were in-patients of Bucharest Clinical Emergency Hospital, either in Endoscopy or in Surgery Departments. Data collected was processed in IBM SPSS Statistics 20. Results: Overall mean age was 51 year and intraabdominal collections average was 109 mm (range 34 250 mm) and was correlated with the method of treatment (p 0.005). Patients underwent different methods for their intraabdominal collections: EUS drainage, CT (computed-tomography)- guided percutaneous drainage, surgical intervention, alone or combined when needed. Overall mortality was 9,3% and was mainly related to the severity of the case and sepsis. Conclusions: We conclude that endoscopic ultrasound can be the first choice for drainage of intraabdominal perigastric fluid collections because it is a safe and effective technique with 100 % technical success, and with over 80 % clinical success assures a better quality of life. For collections with a diameter larger than 127 mm, we can expect however the need of combined treatment, EUS and surgery.

True Negative Predictive Value of Preoperative Staging Endosonography by Combined Endobronchial Ultrasound and Endoscopic Ultrasound in Non-Small Cell Lung Cancer

SESSION TITLE: Interventional Pulmonary Procedures SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: Complete endosonographic mediastinal staging modalities have become a new standard in the pre-operative staging of non-small cell lung cancer in some centers. This study was performed to understand the value of mediastinal lymph node (LN) sampling and dissection at time of pulmonary resection in the setting of a negative pre-operative staging endosonography by combined EBUS & EUS. METHODS: This study consisted of a retrospective, single-institution, tertiary care referral center review of a prospectively maintained database between January 2009 and December 2014. Two hundred and thirty-two consecutive patients with non-small cell lung cancer with negative results on lymph node staging by combined endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) fine needle aspiration (FNA) that subsequently underwent pulmonary resection or attempt at pulmonary resection were included. The endosonographic results were compared with the final pathological staging utilizing final pathology results of lymph nodes sampled during surgery. Chi-Square test was used for statistical analysis. A p-value of <0.05 was considered statistically significant. RESULTS: Twenty-five out of 232 patients with negative results on LN staging by combined EBUS / EUS - FNA had metastases in LNs sampled during pulmonary resection. 10 patients had N1 disease and 15 patients had N2 disease. The negative predictive value (NPV) of EBUS/EUS was 89.2% (p<0.01). Twenty-one out of these 25 patients who had surgical LN sampling at resection did not have the same station sampled pre-operatively by EBUS/ EUS. Therefore a direct comparison at surgical resection could not be made on these 21 patients. Eleven out of these 21 patients had Station 5 and Station 6 involvement and these stations are routinely difficult to sample using endoscopic modalities. If these 21 patients are omitted for comparison, only 4 out of 232 patients had false negative results by EBUS / EUS - FNA giving a true negative predictive value of 98.3% (p<0.01). 3 out of these 4 patients had N2 disease (Station 4L, 5 and 7) and 1 patient had N1 (Station 11R) disease detected at Pulmonary resection. CONCLUSIONS: Staging endosonography by combined EBUS & EUS in potentially resectable patients is associated with a high NPV. If pre-operative results of biopsy of a particular LN station by EBUS/EUS-FNA are negative, then sampling of the same station at surgery can potentially be omitted. LN stations not sampled by endosonography should be sampled at surgery. CLINICAL IMPLICATIONS: Can potentially change the practice and the way lymph node station sampling and dissection is done during pulmonary resection. This may reduce the operative time and avoid unnecessary dissection of the lymph nodes already biopsied at pre operative staging procedure. DISCLOSURE: The following authors have nothing to disclose: Pravachan Hegde, Vicky Thiffault, Vipul Jain, Akshatha Gowda, Pasquale Ferraro, Moishe Liberman No Product/Research Disclosure Information

Primary fallopian tube carcinoma diagnosed with endoscopic ultrasound elastography with fine needle biopsy.

Primary fallopian tube carcinoma (PFTC) is a rare gynecological cancer that is very difficult to diagnose preoperatively. Here, we report the case of a 66-year-old female patient with PFTC that was diagnosed preoperatively on the basis of the characteristic features on endoscopic ultrasound (EUS) elastography and fine needle biopsy (FNB). EUS showed a sausage-shaped hypoechoic mass, 8 cm in size, with irregular margins and heterogeneous internal echoes extending to both adnexa. EUS elastography revealed that the mass had a blue color pattern, representing hard stiffness, and a heterogeneous green/red color pattern distributed outside the tumor, representing intermediate stiffness. Histopathologic analysis of the FNB and operative specimens confirmed the diagnosis of fallopian tube carcinoma. This is the first reported case of a combined EUS elastography and FNB of an adnexal mass leading to a preoperative diagnosis of fallopian tube carcinoma.

A comparative study between combined and separate EUS and ERCP under anesthesia for pancreati- cobiliary diseases

Objective To explore the therapeutic value of endoscopic ultrasonography （EUS） com- bined with endoscopic retrograde cholangiopanereatography （ERCP） for the diagnosis and treatment of pan- ereaticobiliary diseases. Methods Clinical data were analysed retrospectively in patients who underwent both EUS and ERCP in a single anesthetic session （Group A） and separate procedure in two different ses- sions （ Group B）. The following variables of both groups were evaluated ： procedural time, propofol dose, ear- diopulmonary complications, endoscopic complications and diagnostic yield, and therapeutic procedures. Results Procedural time [GroupAvs. GroupB： （ 78. 56±15. 88 ） min vs. （97.78±34.56）mini andthe dose of propofol [ Group A vs. Group B ： （ 314. 21 ± 223.54 ） mg vs. （ 521.23 ± 245.12 ） mg ] differed signif- icantly between both groups （ P 〈 0. 05 ）. In Group A, the diagnostic rates of EUS and ERCP, cardiopulmo- nary complications rate and endoscopic complications rate were 91.4% （96/105）, 81.9% （86/105）, 6. 67% （7/105）, 3.81% （4/105） , respectively, and these variables of group B were 94. 4% （85/90）, 82.2% （74/90） , 5.56% （5/90） , 3.33% （3/90）. There were no significant differences in the diagnostic yield, cardiopulmonary complications and endoscopic complications between the two groups （ P 〉 0. 05 ）. Conclusion It is safe and feasible that EUS combined with ERCP is performed under anesthesia in a single session. It needs a significantly shorter procedural time and smaller dose of propofol compared with separate procedures for pancreaticobiliary diseases. Key words: Anesthesia; Cholangiopancreatography, endoscopic retrograde; Endoscopic uhraasonog- raphy; Pancreaticobiliary diseases

Endoscopic Ultrasound and Magnetic Resonance Cholangiopancreatography in Patients with Idiopathic Acute Pancreatitis

The efficacy of endoscopic ultrasonography (EUS) to diagnose idiopathic acute pancreatitis has been demonstrated but that of magnetic-resonance cholangiopancreatography (MRCP) remains unclear. The aim of our study was to prospectively compare the results of EUS and MRCP to diagnose idiopathic acute pancreatitis when performed later after an acute attack. All patients admitted to our center for acute pancreatitis over a 2-year period received first-line investigations that included medical history, standard biological measurements, abdominal ultrasound, and computerized tomography. If no etiology was found, second-line investigations were scheduled at 2 months (or more if there was severe pancreatitis), which included clinical examinations, biological parameters, EUS, and MRCP. A total of 128 consecutive patients were included (male: 80, mean age: 55.3 years). After first-line investigations, 41 patients with idiopathic acute pancreatitis underwent second-line investigations and were followed-up (38 patients had both EUS and MRCP). EUS and/or MRCP led to recognize a possible etiology of pancreatitis in 19 patients (50 %). The diagnostic yield for EUS was higher than for MRCP (29 vs. 10.5 %). EUS more accurately detected biliary stones whereas MRCP identified pancreatic duct abnormalities, such as intraductal papillary mucinous neoplasm of the pancreas or chronic pancreatitis. The combination of EUS and MRCP, when performed later after idiopathic acute pancreatitis, revealed 50 % of etiologies. The association of these two procedures and the subsequent follow-up reduced the rate of idiopathic pancreatitis by ~66 %.

Pancreatic Duct Compliance After Secretin Stimulation

Endoscopic ultrasound (EUS) evaluation of pancreatic duct compliance after secretin stimulation (sEUS) along with EUS morphologic examination (EUS) and duodenal fluid [HCO3] measurement (endoscopic pancreatic function test, ePFT) in 1 endoscopic session has not been reported as a means of evaluating for chronic pancreatitis (CP). We evaluated the feasibility of the combined examination and compared EUS measurements of pancreatic ductal compliance with duodenal fluid [HCO3] for diagnosing CP.The study is a prospective case series of patients with suspected CP who underwent a combined EUS, sEUS, and ePFT examination in 1 endoscopic session. The main outcome measures were the feasibility of performing the combination examination and the correlation between ductal compliance and ePFT.All examinations were completed in 1 endoscopic session, and there were no complications in 35 patients. Although there was a trend toward less change from baseline head and body ductal diameter in patients with CP, only the percent change from baseline in the tail was significant (CP 144.3% vs healthy patients 240.9%, P < 0.01). Regression analysis demonstrated fair correlation between maximum change in ductal diameter and duodenal fluid [HCO3] (r = 0.27).Combined EUS, sEUS, and ePFTs are feasible and safe, with preliminary results demonstrating a positive correlation between pancreatic ductal compliance and duodenal fluid [HCO3].

Abstract C241: Phase I trial of EUS-guided intratumoral vaccination with recombinant Panvac-F and systemic Panvac-V in patients with locally advanced pancreatic cancer.

Abstract Preclinical studies in our laboratory were the first to demonstrate the superiority of intratumoral poxvirus vaccines in overcoming immune escape and effectively treating murine solid tumor models. We present here the translation of these findings to a Phase I trial in six patients with locally advanced inoperable adenocarcinoma of the pancreas (NCT00669734). The first dose cohort of patients were treated using a combination of EUS (Endoscopic Ultrasound)-guided intrapancreatic tumor injection of recombinant Panvac-F (Fowlpox encoding MUC-1, CEA, TRICOM, 108 PFU) in addition to systemic Panvac-V (vaccinia, 2 × 108 PFU) and Panvac-F (109 PFU) boosts (accompanied by subcutaneous rH-GM-CSF, 100 mcg × 4 days). Patients received a total of 2 intrapancreatic injections of Panvac-F (2 weeks apart) with systemic Panvac-V and Panvac-F boosts given with GMCSF extending to day 71 (total of 2 intrapancreatic Panvac-F, 1 sc Panvac-V, 4 sc Panvac-F). Patients were allowed to transition to standard care at day 31. Patients were evaluated for toxicity, tumor progression, and serum CA 19–9 and CEA levels. Two of six patients were removed from study after approximately two weeks due to rapid disease progression and died one and six months after trial initiation. Of the remaining four, one had received prior treatment with gemcitabine followed by capecitabine and radiation and received no further treatment after vaccination; three received post-vaccination standard treatment with gemcitabine. Of the 4 patients with followup of greater than 6 mos, all have clinically stable disease (15 mos, 13 mos, 12 mos, 9 mos). One pt had a DLT (pancreatitis) that resolved allowing completion of protocol therapy. Results demonstrate that the “first in human” intrapancreatic administration of the full recombinant poxvirus regimen was well tolerated with encouraging stable disease duration. The trial is currently accruing patients at intrapancreatic dose level 2 (109 PFU). This study is supported by the NCI Cancer Therapy Evaluation Program (CTEP) and by NCI U01-CA07031 and P30-CA72720. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr C241.

Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography for Obstructing Pancreas Head Masses

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) are complementary procedures in the evaluation of obstructive jaundice. To determine the feasibility, accuracy, and safety of the combined performance of EUS-guided fine needle aspiration (FNA) and ERCP with biliary stenting in patients with obstructive jaundice. Retrospectively reviewed data from consecutive patients presenting with obstructive jaundice due to a pancreas mass at a tertiary referral hospital between April 2002 and November 2007 who underwent combined (under the same sedation and in the same room) or separate EUS and ERCP. Procedure duration, amount of sedative medication administered, ability to achieve biliary stent placement, and the diagnostic yield of EUS-FNA were evaluated. A total of 47 patients were evaluated: 29 patients underwent combined EUS and ERCP and 18 had separate procedures (median of 5 d between procedures). Stent placement at ERCP was successful in 72% combined procedures versus 88% separate ERCP. EUS-FNA diagnosis of malignancy was positive in 91.6% combined versus 87.5% separate. The only complication was self-limited melena after a combined procedure in 1 patient. The median time for combined procedures was 75 minutes versus 50 minutes for separate EUS and 50 minutes for ERCP. Combined EUS and ERCP can be performed under the same sedation with a median 25 minute greater procedure length and similarly high yields for diagnostic EUS-FNA. A nonsignificant trend toward lower biliary stent placement success rates with combined ERCP procedures merits further study. Benefits of a combined procedure may include expedited patient evaluation and the avoidance of repeated sedation.

Prospective comparison of radial and linear endoscopic ultrasound for diagnosis of chronic pancreatitis

Linear endoscopic ultrasonography (EUS) is currently favored by many endosonographers for the evaluation of pancreatic pathology. However, radial EUS was used in early studies validating EUS for chronic pancreatitis. Radial and linear EUS have never been compared for the diagnosis of chronic pancreatitis. The aim of this study was to compare radial and linear EUS for the diagnosis of chronic pancreatitis using the secretin-stimulated endoscopic pancreatic function test (ePFT) as the reference standard. One hundred consecutive patients evaluated for pain of possible pancreatic origin underwent combined radial EUS, linear EUS, and secretin ePFT during a single endoscopic session. EUS images were acquired on videotape and blindly scored by three reviewers. The main outcome measure was diagnostic accuracy. The accuracy of radial EUS and linear EUS (cutpoint > or = 4 criteria) was 84 % and 74 %, respectively. The statistical test for noninferiority was significant ( P < 0.001) suggesting that the accuracy of radial EUS is as good as or superior to linear EUS. The ratio of accuracy (pi (radial)/pi (linear)) was 1.14 (95 % confidence interval [CI] 0.99 to 1.28). No statistically significant differences were found between radial and linear EUS in terms of sensitivity, specificity, or overall discriminative ability (area under receiver operating characteristic curve 0.84 vs. 0.76, P = 0.10). Interobserver variability was similar for radial (Fleiss' kappa = 0.61, 95 %CI 0.43 to 0.79) and linear EUS (kappa = 0.50, 95 %CI 0.28 to 0.72). The accuracy of radial EUS is as good as linear EUS for the diagnosis of chronic pancreatitis.

Economic analysis of combined endoscopic and endobronchial ultrasound in the evaluation of patients with suspected non-small cell lung cancer

Lung cancer remains the most common cause of cancer-related death in the United States. This study evaluated the costs of alternative diagnostic evaluations for patients with suspected non-small cell lung cancer (NSCLC). Researchers used a cost-minimization model to compare various diagnostic approaches in the evaluation of patients with NSCLC. It was less expensive to use an initial endoscopic ultrasound (EUS) with fine needle aspiration (FNA) to detect a mediastinal lymph node metastasis ($18,603 per patient), compared with combined EUS FNA and endobronchial ultrasound (EBUS) with FNA ($18,753). The results were sensitive to the prevalence of malignant mediastinal lymph nodes; EUS FNA remained least costly, if the probability of nodal metastases was <32.9%, as would occur in a patient without abnormal lymph nodes on computed tomography (CT). While EUS FNA combined with EBUS FNA was the most economical approach, if the rate of nodal metastases was higher, as would be the case in patients with abnormal lymph nodes on CT. Both of these strategies were less costly than bronchoscopy or mediastinoscopy. The pre-test probability of nodal metastases can determine the most cost-effective testing strategy for evaluation of a patient with NSCLC. Pre-procedure CT may be helpful in assessing probability of mediastinal nodal metastases.

Role of Endobronchial (EBUS) and Endoscopic Ultrasound (EUS) in the Diagnosis of Isolated Mediastinal Lymphadenopathy

Introduction: Before the advent of endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS), diagnosis of mediastinal lymphadenopathy required mediastinoscopy or biopsy specimen obtained through open surgical procedure. Surgery and mediastinoscopy are more invasive then EBUS and EUS. Morbidity and mortality rate with conscious sedation has been reported up to 0.06-0.54%. Morbidity rate of EUS-FNA has been reported to be 1-2% with no reported mortality. We have previously shown that the combination of EUS and EBUS provides superior mediastinal staging in patients with lung tumors (Wallace, JAMA, 2008). There is little data on the accuracy of EUS/EBUS in patients with isolated mediastinal lymphadenopathy in the absence of lung tumors. Methods: Combined EBUS and EUS were performed as a part of prospective IRB approved clinical trial in patients with and without lung tumors. Only those patients with isolated mediastinal lymphadenopathy, who have final diagnosis either by EBUS, EUS or by surgical biopsy, were included in this analysis. If either EBUS or EUS alone gave the final diagnosis that was considered to be true positive and was included in the study. Results: We had 16 patients with final diagnosis of their mediastinal lymphadenopathy by either of the above techniques. 4/16 patients had lymphoma, 7/16 patients had sarcoidosis, 1/16 had aspergillosis, 3/16 had metastatic cancer (1 breast, 1 rectal and 1 renal) and 1/16 was benign even after surgical excision. Thirteen out of 16 were diagnosed by EUS with FNA with a sensitivity of 81% (95% CI 0.54-0.95) and specificity of 100%. EBUS with FNA diagnosed 7/16 with sensitivity of 44% (95%CI 0.21-0.69) and specificity of 100%. All the cases which were diagnosed by EBUS were also diagnosed by EUS. Six patients which were diagnosed by EUS were not diagnosed by EBUS. There were three patients which were diagnosed by surgical biopsy and were not diagnosed by either EUS or EBUS. Conclusion: For evaluation of isolated mediastinal lymphadenopathy EUS with FNA alone appears to be adequate in this pilot study. In our study EBUS did not add any further information to the diagnosis. If EUS does not provide the final diagnosis, these patients could possibly be diagnosed with surgically obtained biopsy specimen.

Endoscopic Translumenal Cholecystoscopy and Gallbladder Drainage Using a Novel Lumenal Apposition Device in the Porcine Model

Introduction: The gallbladder is the “final frontier” of biliary endoscopy. Peroral transpapillary cholecystoscopy followed by lithotripsy was recently reported (Chen et al, GIE 2008;67:132). Endoscopic ultrasound (EUS) guided gallbladder drainage has been reported in several case series for acute cholecystitis. This is the first report of translumenal cholecystoscopy and gallbladder drainage using a novel Lumenal Apposition Device (LAD). Aim: Evaluate the feasibility of translumenal cholecystoscopy and gallbladder drainage in the porcine model using the LAD. MATERIALS: The prototype LAD consists of nitinol wire braided heat-set into a dual flange configuration. Fully expanded, the flange and body diameters measure 20 mm and 10 mm, respectively. The body is covered with a coating to prevent leakage and in-growth. The LAD is constrained onto a 10.5Fr delivery catheter. Methods: Four survival pigs were studied under general anesthesia. The gallbladder was located transgastrically using a 3.7 mm channel curved array echoendoscope (Olympus) and punctured with a 19G FNA needle under EUS guidance at a site of abutment against the gastric wall. At least two T-tags (Cook) were deployed to retain apposition of the gallbladder against the gastric wall. The gallbladder was re-punctured at a site adjacent to the T-tags, and a guidewire was inserted through the 19G needle and looped in the gallbladder. Keeping the T-tag sutures under constant traction, the cholecystgastrostomy tract was dilated with a 4 mm non-compliant balloon (Boston Scientific). The LAD (Xlumena) was deployed across the cholecystgastrostomy tract under combined EUS and endoscopic guidance. The deployed LAD lumen was easily intubated with a constrained balloon catheter and dilated to 10mm. Vigorous bile drainage into the stomach was observed after dilation. The echoendoscope was exchanged for a 5.9 mm diagnostic endoscope (Fujinon). The LAD lumen was traversed and the gallbladder lumen entered to perform cholecystoscopy. The cystic duct orifice and deployed T-tags were visualized. The T-tag sutures were cut using endoscopic scissors before withdrawing the endoscope. Results: No acute complications, including bleeding or perforation, occurred. The LAD did not migrate, dislodge or otherwise change position after deployment. There was no evidence of acute tissue injury. Survival data in 4 animals will be presented. Conclusion: EUS guided deployment of the LAD is feasible and enables cholecystoscopy and gallbladder drainage. Further studies are warranted. The LAD can extend the boundaries of interventional biliary endoscopy into the gallbladder.